Written by dr Fiha Seratin
Baby Z, female, is the first child of the couple Ny N and Tn C who was born on December 12, 2016 in hospitals in the region Banjarnegara. By Z came to lactation clinic on February 27, 2017 with a complaint that the baby looks thinner and feels no weight gain.
Weight at birth 3300 grams, when it comes to lactation clinic in Dwi Asih pratama clinic with age 2 months 15 days weight baby Z 3400 gram. Baby’s weight does not increase according to age, only 1.3 grams per day. Infants are in a state of malnutrition according to the World Health Organization’s anthropometry standard (WHO), ie <-3 SD. On examination while in lactation clinic, there is a tongue membrane extending behind the tongue (posterior type) and upper lip membrane thickened grade 3, and baby mother suffered cracked nipples grade 4 on both sides and low milk supply.
Baby Z gets nutrition from breast milk and formula milk. Formula given as much as 2 times then the mother stopped the formula feeding because he wanted to suck directly. Baby Z sucked continuously with a duration of more than 1 hour, if released baby Z will cry again, like no satiety. During sucking suction often loose, clicking, and there is milk out of the corner of the lips (spilling). On physical examination obtained vital signs within normal limits, the weight of the baby only rose 100 grams for 2.5 months, ribs protruding, wrinkled and dry skin. There is a posterior tongue tie and upper lip tie grade 3. baby Z is diagnosed with malnutrition with failure to thrive (FTT) and difficulty sucking due to tongue tie and upper lip tie.
We educate parents about the condition of the baby and the therapy plan that will be given. Parents understand and approve all the therapy to be given. Simple frenotomy therapy was done on tongue tie and upper lip tie to improve attachment when feeding.
Supplementation using naso gastric tube (NGT) number 5F and 50 ml syringe (as shown below) containing pasteurized donor milk or hypoallergenic milk formula if donor milk is not sufficient. Supplementation is given 6 times a day @ 60 ml. Supplementation is performed with the aim of helping to accelerate the increase of Z baby weight and increase mother’s milk production. Parents are taught tongue and lip exercises 5 times a day to prevent post-frenotomy reattachment and routine control every 2 weeks at the Dompet Dhuafa Free Medical Service Lactation Clinic by a pediatrician IBCLC. Mother was given an ointment for blisters that contained 2% miconazole, 2% mupirosine, and betamethasone 0.1% and domperidone at doses of 20 mg 3 times daily to help increase milk production.
The first control after frenotomy (age 3 months 5 days) weight of Z baby rose to 4200 grams, an increase of 57.1 grams per day. Baby’s weight Z is still in less nutritional condition according to WHO anthropometry standard, ie Z score between -2 SD and -3 SD. Supplementation is reduced to 6 × 45 ml daily. Mother taught breastfeeding with football position on the left breast to be more comfortable. The cracked on both nipples begin to improve from grade 4 to grade 3 and mother’s milk is still low milk supply. Therapy for mothers continues.
The second control (age 3 months 16 days) baby weight Z rose to 4400 grams, an increase of 14.3 grams per day. Infant weight gain is not optimal because the supply of donor milk is exhausted and the hypoallergenic milk formula is difficult to obtain in the region where the Z family is living. The baby weight of Z is still under the malnutrition conditions according to WHO anthropometric standards, Z score between -2 SD and – 3 SD. Supplementation is still given as much as 6 × 45 ml daily. The blisters on both nipples improved from grade 3 to grade 2 and mother’s milk began to normal low milk supply. Therapy for mothers continues.
The third control (age 4 months 2 days) baby weight Z rose to 4900 grams, increased 35.7 grams per day. Baby’s weight Z is in less nutritional condition according to WHO anthropometry standard, ie Z score between -2 SD and -3 SD. Supplementation is still given as much as 6 × 45 ml daily. Cracked on both nipples improved from grade 2 to grade 1 and mother’s milk started normal milk supply. The domperidone dose is reduced to 20 mg – 20 mg – 10 mg and the ointment for the blisters continued.
The fourth control (age 4 months 18 days) baby weight Z rose to 5285 grams, increased 24.6 grams per day. Baby’s weight Z is in good nutritional condition according to WHO anthropometry standard, ie Z score right at -2 SD. Supplementation is still given as much as 6 × 45 ml daily. Infant Z is also given complementary food in accordance with the guidance of Indonesian Pediatric Association (IDAI). Infant Z suffered from fever for 3 days and laboratory tests were performed with Hb 7.6 gr / dl, Ht 23%, Tr 245,000, Leu 10.240, LED 19, X Ray chest with normal results, and Mantoux test with negative results. From the results of the examination, Z infants were given iron supplements (Fe) of 2 × 1 ml, Vit C 2 × 25 mg daily, tuberculosis treatment INH 10 mg / kg BW for 6 months, and Vit B6. TB prophylaxis is still given to infant Z despite the negative Mantoux Test and X Ray chest within normal limits because in previous history Z infants are in malnutrition condition where Mantoux test results can give false negative results and contact with tuberculosis patient is positive. The cracked on both nipples begin to heal and breast milk is normal milk supply. The ointment for nipple is stopped and doses of domperidone are reduced to 20 mg – 10 mg – 10 mg.
The fifth control (age 5 months 8 days) baby weight Z rose to 6080 grams, an increase of 39.7 grams per day. Currently Z baby weight is in good nutrition condition according to WHO anthropometry standard, ie Z score right at -1 SD. Supplementation is stopped because nutrition is good and mother’s milk is in normal condition of milk supply. Complimentary feeding was still administered and dose of domperidone was reduced to 10 mg 3 times daily for 2 weeks, then reduced again to 10 mg 2 times daily for 2 weeks, then 10 mg once daily for 5 days and discontinued use.
Control six (7 months 2 days) Z baby weight rose to 7300 grams with an increase of 48.8 grams per day. Baby’s weight Z is in good nutrition condition according to WHO anthropometry standard, ie Z score between -1 SD and Median. Baby Z keeps sucking straight with good complimentary feeding..
In this case, the mother has a determination and a strong desire to keep breastfeeding baby Z even though the mother suffered abrasions on both nipples. Mother is still eager to breastfeed for baby Z to gain weight. Father, grandfather, grandmother, and family support the mother’s attitude to continue breastfeeding. The process of infant weight gain Z can be seen in graph 1.
Graph 1. The process of baby’s weight gain Z
Graph 1. The process of baby’s weight gain Z and Stage Therapy
Reference:
International Standards for Tuberculosis Care: Diagnosis Treatment Public Health 2nd Edition 2009
Recommendation of Indonesian Pediatric Association: Recommendation of Evidence-Based Feeding Practice for Infants and Toddlers in Indonesia to Prevent Malnutrition. UKK Nutrition and Metabolic Disease 2015
Newton BC, Brent AJ, Anderson S, Whittaker E, Kampmann B. 2008. Paediatric Tuberculosis. Lancet Infect Dis august 8 (8): 498-510
Su Jin Jeong. 2011. Nutritional Approach to Failure To Thrive. Korean J Pediatric; 54 (7): 277-281
WHO Child Growth Standard for Girls
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